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You expect your dreams to exist only in your mind while your body rests. But for people with REM (rapid eye movement) behavior disorder, dreaming is much more than mental. It’s a physical and sometimes violent event. REM behavior disorder is a sleep disorder characterized by intense physical activity during REM sleep.

People who experience REM sleep disorder may kick, punch, hit, grab, talk, yell, or leap out of bed while REM sleep is occurring, sometimes injuring themselves or their bed partner. “REM behavior disorder is a dramatic and potentially harmful sleep disorder,” says Tracy Kuo, PhD, a sleep specialist and clinical psychologist at the Stanford Sleep Disorders Clinic in Palo Alto, Calif. “Without treatment, it tends to get worse over time.” The good news is that REM behavior disorder can usually be well managed with proper diagnosis and treatment.

REM Behavior Disorder: No Sweet Dreams

REM sleep disorder is the acting out of dreams during the REM phase of sleep. During sleep, we pass through five phases, the fifth being REM. It’s the most active part of sleep, when most dreaming occurs. As normal REM sleep begins, some minor twitching of the body may occur, but most people don’t actively move their arms and legs enough to allow kicking or punching during REM sleep because the muscles are temporarily immobile. For people with this sleep disorder, however, the temporary paralysis doesn’t happen, allowing movement while dreaming.

“Usually it’s a bad dream or nightmare, where the sleeping person is being chased or attacked,” says Kuo. “He tries to defend himself, leading to punching or kicking, or he may try to get away by jumping out of bed and hitting the bedpost or an object in the bedroom.” This can result in serious injury. According to a University of Connecticut study, the risk for injury to the sleeper or a spouse is as high as 96 percent. Upon waking, the person has no memory of his actions, although he can usually remember the dreams.

REM Behavior Disorder: Men Are at Risk

REM behavior disorder is rare, affecting less than 1 percent of the population. However, more than 90 percent of those with REM behavior disorder are men, usually over age 50. “It’s uncommon in women and children,” says Kuo. “In fact, this sleep disorder is most associated with elderly males.”

The exact cause of REM behavior disorder is unknown, but its onset is associated with several degenerative neurological conditions, especially Parkinson’s disease, and it often precedes Parkinson’s by several years. “Around 30 percent of people with REM behavior disorder develop Parkinson’s disease within three years,” says Kuo. “This suggests that similar brain structures may be involved in both conditions.”

In most cases, REM behavior disorder comes on gradually, worsening over time. When this sleep disorder is sudden and severe, it’s usually caused by drug or alcohol withdrawal.

REM Behavior Disorder: Signs and Symptoms

REM behavior disorder is sometimes confused with sleepwalking and night terrors, but there are differences. People with REM behavior disorder rarely walk or leave their room, are easily awoken, and can remember vivid details of their dreams. On the other hand, people who sleepwalk or have night terrors are usually confused and groggy upon waking and don’t become rapidly alert.

In most cases of REM behavior disorder, a spouse or bed partner, not the person with the disorder, recognizes the problem due to physical or violent activity during REM sleep; these actions may include:

Punching

Kicking

Grabbing

Sitting up in bed

Jumping

Leaping

Shouting

Swearing

REM Behavior Disorder: Treatments and Precautions

REM behavior disorder is treatable with prescription medication. A low dose of a benzodiazepine, usually clonazepam (Klonopin), taken at bedtime is usually effective. It’s unknown exactly why clonazepam helps, but it’s thought to suppress muscle activity during REM sleep. “This medication relieves symptoms in about 90 percent of patients,” says Kuo. One advantage to the drug is that patients don’t usually build up a tolerance to it. Melatonin can also be effective and is sometimes tried as a natural alternative to clonazepam.

In addition to medication, it’s important to make the patient’s sleep environment safe by removing sharp and potentially dangerous objects from the bedroom and putting a cushion around the bed to protect against landing on the floor in case he leaps out of bed during episodes.

Because untreated REM behavior disorder tends to get worse over time, it’s important to see a sleep specialist at the first sign of symptoms.

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